1932172335 NPI number — MR. GEORGE M PROTENIC

Table of content: MR. GEORGE M PROTENIC (NPI 1932172335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932172335 NPI number — MR. GEORGE M PROTENIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROTENIC
Provider First Name:
GEORGE
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932172335
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 N BROAD ST FL 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19107-1500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-479-4142
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
826 MAIN ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIXVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19460-4459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-928-6780
Provider Business Practice Location Address Fax Number:
267-741-0003
Provider Enumeration Date:
02/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  MA000658L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: MA0006581 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1031466560003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".